Monday
Jul282014

Stopping on Green - Part 2

By Laurie Gelb, July 28, 2014

(Read the first installmant of this part post at Stopping on Green

 They Don’t Need No Satisfaction

If/as we rethink the adherence doctrine, with its emphasis on following bottom-up, and begin to consider supporting patients as largely self-informed deciders rather than passive consumers, to what corollaries does that lead?

Imperative 1: Consign “patient satisfaction” to the worm bin, and focus on beliefs and behaviors that drive optimal outcomes.  These are not the same thing. The latter arise from knowledge, experience and culture.  Patients aren’t satisfied, and can’t be, with a product that they hate, fear and continually shy from, unless they seek it out obsessively. They can be content with a single or series of encounters that turn out well, or “the best they could,” but we don’t want them to repeat the experience unless/until they have to, and indeed most of them [the worried well notwithstanding] don’t.  In what other category do we worry about who likes Dr. Smith how much while telling all and sundry that only 10% of the solution rests with Dr. Smith? And speaking of that 90%…

Imperative 2: Disease management that constrains high utilizers’ cost curves while optimizing the outcomes for which we all pay.  As we tell patients continually, but fail to support, we are actually not in charge of managing _their_ disease. To manage disease, we have to support patient, clinician and caregiver choices that avoid duplication, optimize coordination and keep health, not health care, as the laser focus. 

Imperative 3: An an e-health platform that supports all of the above.

E-health is only as good as the health part. It can’t be acceptable to cede EMR design to bureaucrats, process refinement to the business office and online functionality to Webmasters and programmers. 

Baby, I Don't Have a Car

Are we so focused on “consumer-driven care” that we have forgotten to provide consumers with a vehicle to drive toward optimal outcomes? 

We can’t decide to educate simply if/how/when to deviate from our bibles. It doesn’t pay enough for a layperson to learn our bibles. We have to educate in a different way — not simply about vocabulary and labels (the much-touted health literacy, which means about as much as knowing how to read an electrical schematic out loud). 

We can, as any educational program, provide healthcare intelligence. A consumer knows how to change a light bulb and if/how she can rewire a socket. In short, she knows what she doesn’t know. When we preach “follow,” many patients are honestly unsure as to the decisions they have the capacity to make. Then, when they call the overloaded provider’s office to ask about their current concern, we fail to address the underlying uncertainty about the parameters that prompted the question in the first place. Definitions of terms are not a substitute, since knowing what wiring is doesn’t mean I’m off to the junction box.  

The Long and Winding Road

I know that on some freeways, I can exceed the speed limit, but that still doesn’t mean I can drive 100 mph [an action whose commitment time is obviously greater, given braking distances, than if I were driving 70]. I also know that speed can mean death [stakes]. We know that we must never pour a drop of water into a gas tank, to take one example. Or that we should never pour gasoline onto a flame. We are not going to deviate “just a little” to see what happens. How did we internalize, abstract the rationale for these absolutes? We learned something from someone and/or tried it once, depending on our respective backgrounds.

Even when disease management prides itself on counseling small, incremental changes (bring an apple to work!), we are prescribing without insight on either side. If I hate apples, I’m left wondering if it’s comparable to bring a red plum, which I do like. Think about how long that simple question would take to answer via the Internet, and you have a glimpse of the muddy information overload around fruit. And everything else that might be healthy. 

Few of us eat eight servings of fruit and veggies daily (or know how many we ate). We can’t. When as content providers we offer these lofty outcome measures as “information,” consumers roll their eyes, laugh, sigh, blink, snort, tune out and move on. We want and expect them to deviate if/as necessary. In wellness, we encourage them to “do the exercise you like” and eat the greens they like, etc. We don’t say, eat a carrot salad every day because we know they wouldn’t, however good an idea it might be. Yet our most common copy point in command voice is, “Eat [insert official content here].” That implies a literal meaning, for something that we don’t mean. This language is worse than gibberish; it spawns opposition because it rings so far from the truth of daily living. 

Moreover, to apply information, you have to know something about evaluating information quality, relevance and how literally you need to take it.  How are we imparting a health care “street sense?” 

Teach Your Patients Well

If we put on a can of peas the bland, cover-the-bases “content” that populates the major health information sites, human knowledge of peas would come from experience and the “word on the street,” just as it does for other areas in which the “official voice” is seldom heard because it is too opaque. How much of what you know about street drugs comes from officialdom? Amazon can recommend, sales associates can counsel, but for health care, with far greater stakes, there’s canned risk assessments (scripted encounters, waiting room brochures, package inserts, click here for a percentage you’ll need the footnotes to understand). For the obese, the dyslipidemic, the diabetic, the hypertensive, the smokers, we’ve made a better path the ultimate cliché. 

For decades, we’ve said, “We need to teach people the principles of weight management,” while forgetting the public health 101 concept of self-efficacy. If they don’t believe they can’t do it, they won’t even try. Weight management and all the rest of the “good ideas” require a series of choices that many people don’t believe they have the wherewithal to undertake, particularly in the face of an increasingly contradictory evidence base that our nagging letters usually fail to acknowledge at all. We’re not having conversations, as occur whenever you chat with your mechanic; we’re lecturing, pretentiously, and everyone’s falling asleep, only to wake up when the EOB appears.

And then we have the “act as if” faction in our ranks. “Big change is the only way it happens!” Yes, big change can happen if/when someone is scared, cornered, bored, self-impatient, angry, sorrowful. But we’re being paid on outcomes. Can we bank on emotion to inspire often short-lived change? And change from what? Our baseline measurement system is hopelessly flawed. Surveys reveal “the right answer.” Focus groups are pay for-a-play. Claims data reflect reimbursement, less often reality. Medical charts reflect adversarial legal incentives and a shortage of time. Even “real dialogues” during outpatient visits vamp to the camera, and social media monitoring finds the outliers with lightning speed. The best evidence of the real you have at your disposal any time is looking at you in the mirror.

Tell Me Why

Our risk assessment tools don’t allow the patient to contribute the facts that s/he knows best. Clinicians use heuristics to document and chart. Most charted histories omit at least one potentially relevant condition, event or genetic predisposition; it was not on a form, and/or it was not discussed. Many patients also reveal “medical history fatigue” which constrains the completeness of any particular history, and patients who have seen their chart notes are also aware that not all the information they provide is captured, apart from the form itself.  

 Since our brains are small, our days short and we’re only human, just as we have to use heuristics (decision shortcuts) to make everyday decisions about which route to take to work or what to order for lunch, we use heuristics to prioritize, consider, make, avoid, deny, delay and simply tune out myriad health issues and choices.  We’ve failed miserably to convey stakes and commitment times in health care, a lack of knowledge that can only constrain optimal decision-making. If an alien from another planet watched TV or went online for a few minutes, who could blame him for thinking that allergies or erectile dysfunction must be the world’s worst plague? 

It's All in the Game

In short, instead of focusing on an illusory “healthy mindset” whose stock doctrines are breathtakingly obvious (don’t touch the hot stove, stop smoking and cut back on Twinkies), we can more productively allocate all the money spent on bland DM pap to upgrading to the decision support available for silk blouses and video games. 

This week’s stiff-upper-lip letter from a major network, syndicated by a major vendor: …”We understand that there are many reasons why you may not want to take your medication…if you have any questions or concerns, we encourage you to contact your doctor or local pharmacy.”  Talk about “information” that will never be [read or] used! Each two-page letter contains two sentences about the particular drug’s rationale and consequences for not taking it; the rest is unadulterated condescension. How recently was any of your communication…interactive? Inquisitive? Conversational? Brief? 

Direct education in decision-making requires not just doling out information, but encouraging its acquisition through other channels, preaching that it is best leveraged in combination and in understanding, not rote. And then, it falls to MCOs, agencies, clinicians, jurisdictions…anyone with skin in the game, to kick our cheerleaders off the field and start playing full contact football. Our opponents include disease, ignorance, fear, denial, poverty, hunger, addiction and crime. And they've got a large lead. 

Friday
Jul252014

Everything Everyone Had To Say About Halbig and King

By Clive Riddle, July 25, 2014

Much has been written this week about the two conflicting circuit court decisions regarding Affordable Care Act Exchange subsidies - The Halbig v. Burwell decision that found against subsidies for FFE states was celebrated as a decisive blow against Obamacare by opponents; and hours later the King v. Burwell decision that came to an opposite conclusion and dampened, at least a tiny bit, such celebrations.

So is the net effect of the two decisions cause for Much Ado About Nothing, or Much Ado About Everything? Browsing the blogoshpere and articles from major organizations, here’s a sampling of what everyone had to see about the state of affairs in the aftermath – with some of the rhetoric a bit over-caffeinated and some seemingly more balanced:

Given these were not SCOTUS decisions, the question is – what’s next? Margot Sanger-Katz of the New York Times answers that question in her article After Health Law Rulings, Here Are Possible Next Steps in which she spells out these scenarios and steps:

  1. All the judges on the D.C. Circuit could decide the Halbig v. Burwell case.
  2. The law’s challengers could ask the Fourth Circuit to reconsider King v. Burwell.
  3. Decisions will be issued by other courts.
  4. Either side — or both — could appeal the rulings to the Supreme Court. T
  5. The Supreme Court could decide the case.
  6. Congress could act.
  7. States could act.

A Kaiser Health News article, New Health Law Court Decisions Could Have Limited Political Impact counsels that the decisions aren’t going to turn mid-term elections on their head: “Political analysts say this week’s court decisions on the legality of tax subsidies for those obtaining coverage under the Affordable Care Act may not have a broad impact on this fall’s midterm elections. The decisions sent a mixed legal message, complicating the political message as well. One appellate court panel ruled the subsidies cannot be provided in the 36 states relying on the federal insurance exchange; the other ruled in favor of the Obama administration, saying Congress intended that the subsidies be available regardless of whether states operated their own insurance marketplaces. Political candidates as well as voters will have to wait until the outcome of appeals of the cases to know their impact. But that didn’t stop some politicians from trying to immediately exploit the issue.”

If you are looking for a nice in-depth discussion of the situation – consider giving Timothy Jost’s Health Affairs Blog that provides such coverage: Implementing Health Reform: Appellate Decisions Split On Tax Credits In ACA Federal Exchange. He writes in part: “The issue in the cases is this: The ACA authorizes the IRS to provide premium tax credits to individuals with household incomes between 100 and 400 percent of the federal poverty level who are not eligible for other minimum essential coverage (such as affordable and adequate employer coverage, Medicaid, or Medicare). Premium tax credits are, however, only available to individuals who purchase coverage through the exchanges. The ACA requests that the states establish exchanges, and sixteen states and the District of Columbia have done so. The ACA also, however, authorizes the federal government to establish exchanges in states that fail to set up their own exchanges. The federal government has done so in 34 states and is operating the individual exchange for two more. The IRS regulation allows premium tax credits to be awarded to eligible individuals in both states with state-operated exchanges and states with federal exchanges. Two subsections of the ACA, which describe how the amount of tax credits are to be computed and what months can be covered by tax credits, however, provide that tax credits are available for months in which an individual is enrolled in a qualified health plan “through an Exchange established by the State under 1311” of the ACA. The plaintiffs in the King and Halbig cases argue that this provision bars the IRS from issuing premium tax credits to individuals who enroll in qualified health plans through federal, as opposed to state-operated, exchanges.”

What are the stakes? Tim tells us “these cases, as well as two other cases pending in the federal district courts in Oklahoma and Indiana brought by the attorneys general of those states, have clearly been brought for a political purpose — to bring down the ACA.”

But the last word on this for today perhaps should belong to John Stewart, who Adrianna McIntyre notes in her Vox Healthcare Blog: Still confused about the latest Obamacare lawsuits? Let Jon Stewart explain (which includes the video clip) “Stewart commended the judges on getting past stop signs the morning of the decision. ‘Until the law expressly provides a 'go' sign, we can in no way ascertain the intent of the framers of the sign. Surely the people honking behind me appreciate the rigor of my judicial acumen.’

Friday
Jul182014

All Things to All People Isn't Working

By Kim Bellard, July 18, 2014

When it comes to hospitals, we may need to paraphrase Lincoln: they can treat all of the people some of the time, and some of the people all the time, but they can't -- or, rather, they shouldn't -- try to treat all of the people all of the time.

US News & World Report just released their annual "Best Hospitals" rankings.  They evaluated nearly 5,000 hospitals against a detailed methodology

What struck me was that, out of those nearly 5,000 hospitals, only 144 scored a national ranking in even one specialty.  None -- I repeat that, none -- ranked in all 16 specialties.  Only Boston, Los Angeles, and New York had more than one Honor Roll hospital.  Several states have no hospital with a national ranking in any specialty.

There's a lesson there.

A few days ago Clayton Christensen, the Harvard-based guru of "disruptive innovation," told Forbes that the U.S. health industry is "sick and getting sicker."  He offered several suggestions for what he thinks need to change, but I want to pick one in particular, his emphasis on cutting administrative waste.  

It is not unusual to cite administrative waste as a problem in our health care system, but Christensen comes at it from a different angle.  As he said:

An increasing proportion of [health care] cost is spent on administrative and overhead activities that are not productive in any way.  They exist because we assume every hospital should be able to do everything for everybody. But that’s not possible if we want quality and efficiency. Overhead creep is the result.


Toby Cosgrove, the CEO of The Cleveland Clinic, gets it as well (or at least, says the right things).  As he recently said at the Aspen Ideas Festival: "What we need to understand is that not all hospitals can be all things to all people."

Cosgrove noted The Cleveland Clinic's expertise in cardiothoracic surgery, done on a scale that he believes results in care that is cost-effective and of high quality.  They draw patients for these services not just from their metro area, their region, or even just the U.S., but also internationally.  He wants to see a future where we get patients to the right physicians, rather than trying to have expertise available everywhere.

Given the solid data on the importance of volume/experience, then, why are each of my local hospitals trying to make themselves the leader in, say, open heart surgery?  Or in cancer, neurology, or sports medicine for that matter? 

Somehow it is hard for me to believe they've got my interests -- the patient's interests -- as their top priority.  

Becker's Hospital Review recently hosted an Executive Roundtable on affiliation, and I was struck by a comment one of the hospital CEOs made:

There are too many tertiary facilities' values are not aligned with rural hospitals' values: Their goal is to pull patients out of smaller communities, which is not what smaller communities are looking for in an affiliation. Keeping patients close to home is what's important.

Wouldn't you like to think that doing what is best for the patient is what's important? 

The point is, most of us don't live in places where we should be expecting that we're going to get the best care for every condition locally.  Nor should we expect that even the "best" hospital/health system for some conditions are best for other conditions as well.  Who is treating you where for what matters.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Thursday
Jul102014

State Health Care Prison Spending by the Numbers

by Clive Riddle, July 10, 2014

The State Health Care Spending Project, an initiative of The Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation, has been monitoring and analyzing prison healthcare costs for some time, and Pew has just released a new 32-page report: State Prison Health Care Spending: An Examination.

This is on the heels of their report Managing Prison Health Care Spending first released last October, which covered the period of 2001 – 2008, and found that spending sharply increased in most states during that time period. The new report analyzes spending from 2007 – 2011 and found “state spending on prisoner health care increased from fiscal years 2007 to 2011, but it is trending downward from its peak in 2009.”

The new report concludes: “Correctional health care spending poses a fiscal challenge to state lawmakers, though evidence indicates that spending peaked at the end of the last decade. The situation posed by these expenses may be particularly acute in states where older inmates represent a relatively large proportion of the prison population. Corrections officials will be better positioned to manage their systems effectively with access to rigorous, disaggregated spending and health outcomes data that can be used to identify cost drivers and to evaluate the value and impact of cost-containment initiatives.”

Here’s a compilation of various analysis and findings from the new report, by the numbers:

4 key variable characteristics that affect delivery of health care and increase costs include: (A) Prison population trend; (B)  Older inmates, greater expense; (C) Prevalence of disease and mental illness. And (D) Location and inmate transportation.

4 strategies being used to manage costs are: (A) use of telehealth technologies; (B) outsourcing of prison health care, (C) enrollment of prisoners in Medicaid, and (D) appropriately paroling older and/or ill inmates.

37% of health care spending was on general medical care (20% was on hospitalizations; 14% on pharmaceuticals; 14% on mental health; 5% on substance abuse)

39 States saw per-inmate health care spending rise from fiscal 2007-2011, with a median growth of 10%.

41 States experienced growth in their correctional health care spending from fiscal 2007-2011, with a median increase of 13%.

34 States saw their total correctional health care spending peak before fiscal 2011

40 Of 42 states surveyed experienced a rise in the share of older inmates from fiscal 2007-2011

204% increase in the number of state and federal prisoners age 55 and older

from 1999–2012

$441 million - The amount of California’s decrease in spending from fiscal 2009 to 2011 accounting for most of the national decline of half a billion dollars during that time

$7.7 billion total prison health care spending in fiscal 2011

$8.2 billion total prison health care spending in fiscal 2009

Wednesday
Jul092014

One in 5 million Americans now covered by Medicaid

By Claire Thayer, July 7, 2014

The Affordable Care Act (ACA) has had a huge impact on Medicaid enrollment and spending since the expansion of Medicaid eligibility to include almost all adults with incomes at or below 138% of the federal poverty level effective January 1, 2014. The Kaiser Family Foundation recently released, Medicaid Moving Forward, a concise fact sheet summarizing current enrollment, spending and other trends for the Medicaid program.  Lots of data is packed into this fact sheet, here are a few of the important highlights:

Who Does Medicaid Cover?

  • Over 66 million Americans now receive their health coverage through the Medicaid

  • Medicaid and Children’s Health Insurance Program (CHIP) cover more than 1 in every 3 children

  • In June 2013, over 28 million children were enrolled in Medicaid and 5.7 million were enrolled in CHIP

  • The ACA expanded Medicaid to nearly all adults under age 65 with income at or below 138% FPL, effective January 1, 2014.

  • As of June 2014, 27 states, including DC, were expanding Medicaid, three states were actively debating the issue, and 21 states were not moving forward

What does Medicaid Cover?

  • inpatient and outpatient hospital services;

  • physician, midwife, and nurse practitioner services;

  • early and periodic screening, diagnosis, and treatment (EPSDT) for children up to age 21;

  • laboratory and x-ray services;

  • family planning services and supplies;

  • federally qualified health center (FQHC) and rural health clinic (RHC) services;

  • freestanding birth center services (added by ACA);

  • nursing facility (NF) services for individuals age 21+;

  • home health services for individuals entitled to NF care;

  • tobacco cessation counseling and pharmacotherapy for pregnant women (added by ACA);

  • non-emergency transportation to medical care

How do Medicaid Beneficiaries Get Care?

  • Most Medicaid beneficiaries obtain care from private office-based physicians & other health professionals.

  • Safety-net health centers and hospitals also play a major role in serving the Medicaid population.

  • Over half of Medicaid beneficiaries nationally, mostly, children and parents, are enrolled in comprehensive managed care organizations (MCO) that contract with states on a capitation, or risk, basis to deliver Medicaid services

  • A smaller but still significant number of beneficiaries are enrolled in Primary Care Case Management (PCCM) programs

How much does Medicaid cost and how is it financed?

  • In FY 2012, Medicaid spending on services totaled about $415 billion

  • Administrative costs accounted for 5% of overall program spending.

  • Two-thirds of all spending on services was attributable to acute care

  • 30% of all spending on services was associated with long-term care.

  • Supplemental payments to hospitals that serve a disproportionate share of Medicaid and uninsured patients, known as “DSH,” accounted for about 4% of spending

  • Medicaid payments for Medicare premiums and cost-sharing on behalf of dual eligible beneficiaries totaled 3.5%.

Source: Medicaid Moving Forward, The Henry J. Kaiser Family Foundation, June 17, 2014.

Additional Issue Briefs that might be of interest:

Katherine Young and Lisa Clemans-Cope and Emily Lawton and John Holahan, Medicaid Spending Growth in the Great Recession and Its Aftermath, FY 2007-2012, The Henry J. Kaiser Family Foundation, Issue Brief, July 3, 2014.

Samantha Artiga and Robin Rudowitz, Medicaid Enrollment Under the Affordable Care Act: Understanding the Numbers, The Henry J. Kaiser Family Foundation, Issue Brief, January 29, 2014.